ATTACHEMENT A
Emergency or Medical Treatment
Consent Form
In the event of an emergency or for medical treatment, I hereby give my consent and authorize the
University Health Service or the closet Hospital Emergency Department to provide medical services for
me. It is understood that this authorization is given in advance of any specific diagnosis, treatment or
medical care being required, and is to serve as specific consent to any and all such diagnoses, treatment or
hospital care, which may be deemed desirable.
APPROVED MEDICAL PROCEDURES FOR: (Please Print)
_____________________________________________
Full Name (Please Print)
_______________
Date of Birth
_____________________________________________
Signature
_______________
Date
EMERGENCY CONTACT INFORMATION
________________________________________
Name
_______________
Relationship
____________
Phone
_____________________________________________________ ____________________
________________
Name
Relationship
Phone
REQUIRED HEALTH HISTORY
Current Medications:____________________________________________________
Allergies to drugs, medicines, plants, food:_____________________________________
Have you ever had: (Answer Yes or No)
___Rheumatic Fever
___Heart Disease
___Asthma
___Hay Fever
___Anemia
___Bladder, Kidney Infection
___Tuberculosis
___Hepatitis
___Persistent Migraine Headaches
___Pelvic Infection
List any other pervious illness, injury or surgery___________________________________
List any chronic illnesses or physical limitations (use of wheelchair or walker)
________________________________________________________________________
Identify approximate immunization dates:
_________Tetanus
________Measles
INSURANCE INFORMATION
__________________________ ___
Name of Insurance Company
____________________________
I.D. or Contract Number
_____________________________
Policy Holder’s Name
____________________________
Service Code or Insurance Number
(_______)_____________________
Policy Holder’s Phone Number
____________________________
Group Numbers or Policy Numbers
________________________________________________________________________
Policy Holder’s Address
State
Zip
______________________________
Relationship to Insured
I request that payment under my medical insurance program be made directly to the site of services
rendered. I understand that I am financially responsible for fees not covered by this authorization.
__________________________
Full Name (Please Print)
_________________________________
Address
__________________________
Signature
_________________________________
City
State Zip
(_____)____________________
Home Phone
__________________________
Date
(_____)__________________________
Work Phone